CENTRAL MOTOR VEHICLES RULES, 1989 FORMS Form1[See Rule 5 (2)] Application - cum - declaration as to physical fitness 1.Name of the applicant .................... 2.Son/ Wife /Daughter of .................... 3.Permanent Address .................... 4Temporary Address .................... Official Address (If any) .................... 5.(a) Date of Birth .................... (b) Age on Date of application .................... 6. Identification Mark (!) .................... Declaration (a) Do you suffer from epilepsy or from sudden attack of loss of consciousness or giddiness from any cause? Yes /No (b) Are you able to distinguish with each eye (or if you have held a driving license to drive a motor vechile for a period of not less than five years and if you have lost, the sight of one eye after the said period of five years and if the application is for driving a light motor vechile other than a transport vechile fitted with an outside mirror on the steering wheel side) or with one eye, at a Yes /No distance of 25 meters in good day light (with glasses, if worn) a motor car number plate? (c) Have you lost either hand or foot or are you suffering from any defects in movement, control or muscular power of either arm or leg.? Yes /No (d) Can you readily distinguish the pigmentary colors, red and green? Yes /No (e) Do you suffer from night blindness? Yes /No (f) Are you so deaf so as to be unable to hear (and if the application is for driving a light motor vehicle, with or without hearing aid) the ordinary sound signal? Yes /No (g) Do you suffer from any other disease or disability likely to cause your Driving of a motor vehicle to be source of danger to the public, if so, give details. Yes /No I hereby declare that, to the best of my knowledge and belief, the particular given above and the declaration made therein are true. Note:-(1) An applicant who answer "Yes" to nay of the question (a), (c) (e), (f) , (g) or "No" to either of the question (b) ,(d ) should imply his answer with full particulars, and may be required to give further information relating thereto. (2 ) This Declaration is to be submitted invariably with medical certificate in Form 1-A.
